Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD
Appellate Division
SUBJECT: New York State
Department of Social Services
Docket No. 90-230
Decision No. 1218
DATE: January 23, 1991
DECISION
The New York State Department of Social Services (State) appealed
a
determination by the Health Care Financing Administration
(Agency)
disallowing federal financial participation (FFP) in the amount
of
$1,720,388 claimed under title XIX of the Social Security Act for
the
quarter ended September 30, 1988. The costs claimed represented
amounts
originally paid under the State-funded medical assistance program
which
the State later claimed as payments for individuals eligible
for
Medicaid. The State used statistical sampling procedures to
estimate
the amount paid to individuals who were eligible for Medicaid on
the
basis of disability.
The State requested a summary decision upholding the disallowance based
on
New York State Dept. of Social Services, DAB No. 1012 (1989).
Similar summary
decisions have already been issued by the Board. See
New York State
Dept. of Social Services, DAB No. 1197 (1990), and cases
cited therein.
In DAB No. 1012, the Board held that the State was not authorized to
use
statistical sampling as a basis for claiming Medicaid funds payable
on
behalf of disabled individuals. The Board found that sampling
was
impermissible because it was used in lieu of making the
disability
determinations which the regulations, reasonably interpreted,
require in
each case for which payment is made. Accordingly, the Board
sustained
the disallowances to the extent that they represented
extrapolations
from cases in the sample involving individuals eligible for
Medicaid
based on disability. The Board remanded that part of the
disallowances
pertaining to the cases in the sample to determine whether
the
disability determination in each case was properly made.
The Agency agreed to the issuance of a summary decision here based on
DAB
No. 1012. Letter from Healy to Settle dated 1/16/91.
Conclusion
Accordingly, based on the analysis in DAB No. 1012, we uphold
the
disallowance to the extent that it represents disability-based
claims
calculated by extrapolation from a statistical sample. As in
that
decision, we remand to the Agency that part of the disallowance
which
pertains to the cases in the sample to determine whether the
disability
determination in each case was properly made so that FFP is
allowable.
1/ The State may appeal the Agency's determination in the
sample cases
pursuant to 45 C.F.R. Part 16.
________________________ Donald F. Garrett
________________________ Alexander G. Teitz
________________________ Norval D. (John) Settle Presiding
Board
Member.1. In some related appeals, the Agency asserted, and
the
State did not dispute, that claims for the expenditures made
on
behalf of the individuals in the sample cases were not
included
in the amounts in dispute. Docket Nos. 89-51, 89-86 and
89-87,
Agency's brief dated 6/1/89, p. 5. If the same is true
here,
there would of course be no need for further
Agency